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' • • 4 • • le,,UR <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY O t NEW PERMIT 3 RENEWAL PERMITS CHANGE OF INFORMATION O 7 PERMAN CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> nRAORFACT ITYNAME NAMEOFOPERATOR <br /> ADDRES NEAREST CROS$,$T EET PAACEU(oPrioNAW <br /> CITY NAME , J` STATE , Zld` DE SITE PHONE 0 WITH AREA CODE <br /> a CA 4 57a 05 <br /> TOINDICATE 77:1 CORPORATION INDIVIDUAL Q PARTNERSHIP LOCAL-AGENCY Q COUNTY AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner d UST Is a public agency,conpide the following:name of Supervisor of division.section,or office which operates the UST <br /> TYPE OF BUSINESS Q 1 GAS STATION 0 2 DISTRIBUTORO ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(aptional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR = 5 OTHER ORTRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME m r IT ^ 1+ CillEA) CAREOFADDRESS INFORMATION <br /> MAILING OR STREET ADDR ' 7F r ✓bor b Indicate INDIVIDUAL O LOCAL-AGENCY STATE AGENCY <br /> CORPORATION (] PARTNERSHIP (] COUNTY-AGENCY 0 FEDERAL <br /> CITY N E a STATE ZIP C D PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF NE If, CAREOF DDRESSINFOR ATION <br /> RE <br /> MAILING R STREET EBS f� ✓box to Nicee INDIVIDUAL OLOCAL-AGENCY [-ISTATE-AGENCYS I a =CORPORATION O PARTNERSHIP COUNTY AGENCY ] FEDERAL <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> r O &ff <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ M44- -=: <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box binEbale f=I SELF-INSURED (]2 GUARANTEE 3 INSURANCE O 4 SURETY BOND <br /> E=1 5 LETTEROFCREDIT ]6 EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[—] It.F] If <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAM E(PRINTED a SIGNED) OWNER'S TITLE DATE MONTWDAWY'EAR <br /> LOCAL AGENCY USE ONLY eOb3 kj <br /> COUNTY# JURISDICTION# .7357 <br /> LOCATION CODE -OPTIONAL CENSUSTRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> C) 3 : O <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS S A CHANGE OF REIN ORMATION ONLY. <br /> FORM A(3'93) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS-/ l FOR00]]A{iT <br /> /-I cQd l,*r /!1� V ""-Jl 1�T�i� f� <br />